Accreditation and Regulatory Compliance Specialist

HealthPartners•Saint Paul, MN

19h•Hybrid

About The Position

Regions Hospital is seeking an Accreditation and Regulatory Compliance Specialist to advance continuous regulatory readiness and accreditation excellence. The role leads planning, implementation, and sustainment of initiatives that reduce organizational risk, strengthen patient and staff safety, and support compliance with applicable regulations, statutes, and accreditation standards. Working with the Manager of Accreditation and Regulatory Compliance, the specialist advises leaders, departments, and multidisciplinary teams and leads or participates in onsite and virtual accreditation surveys, regulatory investigations, and external agency reviews. The specialist collaborates with operational and clinical leaders to identify compliance risks, conduct assessments, develop corrective action plans, and implement sustainable improvement strategies. The role promotes regulatory awareness and organizational compliance in support of high reliability and excellence in patient care. It reports to the Manager of Accreditation and Regulatory Compliance and partners with accreditation and compliance leaders at Regions Hospital and Methodist Hospital. Approximately 75% of the work supports Regions Hospital; the position also works with Methodist’s Regulatory Compliance Program Manager to advance readiness and compliance across both organizations. This is a hybrid position requiring onsite work three days per week, typically Tuesday through Thursday, with additional onsite presence as needed. Hours are Monday through Friday during core business hours. The compensation range is $43.42–$65.14 per hour; pay may vary based on factors including education, experience, skills, location, abilities, and internal equity. Additional compensation may be available based on the role.

Requirements

Bachelor’s degree and at least three years of healthcare-related project-management experience, or an equivalent combination of education and experience.
Two years of experience in accreditation, regulatory compliance, quality, risk management, patient safety, clinical operations, or a related healthcare function.
Working knowledge of accreditation and regulatory standards, including The Joint Commission (TJC), Centers for Medicare & Medicaid Services (CMS), Minnesota Department of Health (MDH), and other applicable agencies.
Familiarity with OSHA regulations, building codes, and fire and life safety standards.
Proficiency with Microsoft Word, Excel, PowerPoint, and Outlook.
Strong written, verbal, and interpersonal communication skills, including the ability to communicate effectively across organizational levels.
Critical-thinking, analytical, problem-solving, and decision-making skills.
Ability to manage multiple priorities, adapt to changing demands, and meet competing deadlines in a fast-paced environment.
Strong organizational and project-coordination skills, including scheduling and managing complex meetings, calendars, and work plans.
Ability to work independently and collaboratively.
Ability to build and maintain positive working relationships with frontline staff, leaders, physicians, and other stakeholders.
Experience collecting, analyzing, interpreting, and presenting data through reports, presentations, and other communication tools.
Knowledge of evidence-based practices related to patient safety, regulatory compliance, and healthcare quality improvement.
Ability to conduct risk assessments, identify improvement opportunities, and support corrective-action planning.
Exceptional attention to detail and ability to maintain accurate records and documentation.
Ability to handle sensitive and confidential information professionally and discreetly.

Nice To Haves

Experience in ambulatory or outpatient healthcare settings.
Master’s degree.
Certified Professional in Healthcare Quality (CPHQ) credential.

Responsibilities

Proactively assess organizational compliance status and develop action plans to mitigate risk and improve regulatory readiness.
Lead, plan, and execute initiatives, projects, and risk-reduction strategies that build a culture of high reliability across service lines and departments.
Monitor upcoming changes and new accreditation or regulatory requirements, partnering with leaders and subject matter experts on gap analyses and risk assessments.
Use audits and tracers to monitor, report, and address clinical and environmental risk areas.
Evaluate and surveil patient and clinical processes, systems, and environments for regulatory compliance, including leading and participating in Environmental Safety Rounds in patient-care and non-patient-care areas.
Create and maintain a compliance scorecard or dashboard to visualize compliance metrics and manage the intra-cycle monitoring process.
Analyze compliance data to identify improvement opportunities and assess risks to patient and staff safety.
Lead process-improvement initiatives to mitigate significant risks and engage leaders and subject matter experts in closing compliance gaps.
Assess and benchmark practices and network with hospitals locally and nationally to identify best practices.
Apply project-management, quality, and problem-solving methodologies.
Plan and facilitate onsite and virtual accreditation surveys and regulatory complaint investigations, including preparation, survey implementation, post-survey action planning, follow-up, and compliance monitoring.
Facilitate accreditation and regulatory surveys and investigations; lead information gathering for external agency requests and formulate responses to external agency inquiries.
Develop and revise work standards and job aids for surveys and related processes.
Develop and present regulatory-readiness curriculum and training content.
Create organization-wide Huddle and Brief messages and other communications about regulatory standards and focus areas.
Develop regulatory education and guidance for target audiences, including lunch-and-learn sessions and newsletters.
Plan, facilitate, and participate in teams and committees supporting improvement and continuous regulatory readiness; represent the department on hospital-wide and system-wide committees.
Provide consultative services to policy owners and review document drafts for regulatory clarity, consistency, and compliance.